‘IF YOU CAN NOT EXPLAIN IT SIMPLY, YOU DO NOT UNDERSTAND IT

WELL ENOUGH’
Albert Einstein
LEADING CAUSE OF MATERNAL
MORTALITY :
HYPERTENSIVE DISORDERS OF PREGNANCY :

spektrum klinis hipertensi kehamilan

Chronic Hypertension
Gestational Hypertension 149/90 tp gaa ada proteinuria, ga ada 5 penylit
lain
pada kehamilan lebih dari 20 mgg

Preeclampsia
Superimposed Preeclampsia pasien hipertensi kronis ditemukan sebelum
20 minggu, dalam perjalan 20 minggu
ditemukan proteinuria atau 5 penylit lain
PREECLAMPSIA

New onset hypertension (≥ 140/90 mmHg, at

least twice, 6 hours apart in the absence of
chronic hypertension) and proteinuria (300 mg
in 24 hours in women without prior
proteinuria) that begins after 20 weeks
gestation
 tsetelah 2016, kriteria poretinuria ga hrs ada

suda
h
mas
uk
pada

prek
ekm
plasi
a
preeklamsia berat, bila salah satu di bwh ini ditemukan

pasien 140/90, ada tromnositopeni : prekeklamsia

140/90 ga ada trombositopeni : prekekmlasia berat
140/90 ada edem paru : prekelamsia berat
HYPERTENSIVE DISORDERS OF PREGNANCY :

Chronic Gestational
Clinical Findings Preeclampsia
Hypertension Hypertension
Time of onset Usually in third
< 20 weeks ≥ 20 weeks
hypertension trimester
Degree of
Mild or severe Mild Mild or severe
hypertension
Proteinuria Absent Absent Usually present
Serum urate > 5.5 Present in almost
Rare Absent
mg/dl (0.33 mmol/L) all cases
Hemoconcentration Absent Absent Severe disease
Thrombocytopenia Absent Absent Severe disease
Hepatic dysfunction Absent Absent Severe disease
Clinical Spectrum of Preeclampsia :

• Non-severe Preeclampsia
• Severe Preeclampsia
• Eclampsia
• HELLP syndrome
SEVERE PREECLAMPSIA

• Blood pressure ≥160 mmHg systolic or ≥ 110 mmHg on two

occasions at least 6 hours apart while the patient is on bed rest
• Oliguria(< 500 mL in 24 hours)
• Cerebral or visual disturbances
• Pulmonary edema or cyanosis
• Epigastric or right upper quadrant pain
• Impaired liver function (AST and orALT ≥ 70 U/L)
• Thrombocytopenia (<100.000/mm3) and or evidence
of microangiopathic hemolytic anemia
ECLAMPSIA

klo ga ada preeklamsia tpi tau2 kejang, DD nya epilepsi.

HELLP SYNDROME

trombositopeni
PATHOPHYSIOLOGICAL PROCESS

penyeabbnya gatau. selain karna hamil.

• Genetic predisposition
• Inadequate throphoblast invasion of spiral arteries
• Reduced uteroplacental perfusion placent
• Placental damage (leading to apoptosis)

• Release of circulating factors or

placental syncytial fragments
• Exaggerated maternal immune response
• Endothelial cell dysfunction
ada sel trofoblost yang sinsio berhadapan degn desidua, yang jalan2 sito trofoblast menginvasi arteri sprialis, mengganti sel lebih flkasibel dan besar. Tpi klo
ngga ada invasi, maka lumen akan kecil
Preeclampsia signs & symptoms :
Cerebral Headache kadang sama pasien, jadinya ga terlalu jelas sign nya

Dizziness
Tinnitus
Drowsiness
Change in respiratory rate
Tachycardia
Fever
Preeclampsia signs & symptoms :

Visual Diplopia
Scotoma
Blurred vision
Amaurosis
Preeclampsia signs & symptoms :
gangguan severe hepar -> akan mual munrah

Gastrointestinal Nausea
Vomiting
Epigastric pain
Hematemesis
Preeclampsia signs & symptoms :
Renal Oliguria
Anuria
Hematuria
Hemoglobinuria
PREECLAMPSIA
COMPLICATIONS

• Gestational age at time of

diagnosis
Complications • Severity of disease
depend on : • Presence of other medical
conditions
• Management
PREECLAMPSIA COMPLICATIONS
(MATERNAL)

HELLP syndrome

DIC

Pulmonary edema severitas

Abruptio placentae

Renal failure severitas

Eclampsia spektrum klinis

Cerebral hemorrhage
PREECLAMPSIA COMPLICATIONS
(FETAL)

fetal origin disease, jadi di 40 tahun

udh sakit. yang harus nya masi tua
nanti
MANAGEMENT OF PREECLAMPSIA
COMPLICATIONS

 The primary aim is immediate elimination of the disease

phenotype

• Termination of pregnancy with the least possible trauma to

mother and fetus
• Birth of an infant who subsequently thrives

• Complete restoration of health to the mother

DELIVERY IS THE ONLY
CURRENT CURE
MANAGEMENT OF PREECLAMPSIA
COMPLICATIONS

 Timing of delivery

• ≥ 34 weeks survival lebih baik

There is universal agreement that all patients should be

delivered
• < 34 weeks
 Delivery vs expectant management ?
Although delivery is always appropriate for the mother
it may not be optimal for the fetus
MANAGEMENT OF PREECLAMPSIA
COMPLICATIONS

Magnesium sulphate
Intravenous 4 gr loading dose over 20
minutes is given followed by the
maintenance dose of 1-2 gr per hour

kompetensi 3B, melakukan tatalaksana awal

MANAGEMENT OF PREECLAMPSIA
COMPLICATIONS

• Labetalol
• 20 – 40 mg IV every 10 – 15 minutes as
needed for a maximum of 220 mg
• Nifedipine yang dipake di INDOOOO
• 10 – 20 mg orally may repeat in 30 minutes
for a maximum dose of 50 mg
• Hydralazine
• 5 – 10 mg IV every 20 minutes for a
maximum dose of 20 mg
• Sodium nitroprusside
• Rarely needed
• Start at 0.25 µg/kg/min to a maximum of 5
µg/kg/min

Antihypertensive
agents
MANAGEMENT OF PREECLAMPSIA
COMPLICATIONS

Management of delivery

• Choice of mode of delivery

• Continuous fetal monitoring
• Intravenous access
• Fluid balance chart
• Reguler blood pressure monitoring
• Good analgesia
• Active management of the 3rd stage
• If requires CS, regional anesthesia is preferable
MANAGEMENT OF PREECLAMPSIA
COMPLICATIONS

Immediate postpartum care

• Reguler blood pressure monitoring
• Strict input-output chart
• Magnesium sulfate infusion continued for 24 hours
• Anti-hypertensive should be continued or reduced slowly
Diuretics should only be given if there is evidence of pulmonary
edema function,
• Check full blood count, clotting function, renal liver enzymes
and urate
PREVENTION IS
THE BEST
PRACTICE
PREVENTION IS THE BEST
PRACTICE

• Pre-conception care
• Antepartum care
• Intrapartum care
• Postpartum care and follow up
PREVENTION IS THE BEST
PRACTICE

Pre-conception care
Pre-existing risk factors :
• Family history of preeclampsia
• Previous history of preeclampsia
• Increased maternal age
• Low socioeconomic status
• Obesity
• Hypertension
• Diabetes mellitus
• Renal disease
• Cardiac disease
• Thrombophilia
• Autoimmune disease
PREVENTION IS THE BEST
PRACTICE

Pre-conception care
Pregnancy related factors :
• Primigravida
• First pregnancy with new partner pernikahan pertama kali dengan beda suami

• Pregnancies conceived withART

• Multiple pregnancy
Risk factors Frequency of occurrence
Previous preeclampsia 20-30%
Previous preeclampsiaat ≤ 28 weeks 50%
Chronic hypertension 15-25%
Severe hypertension 40%
Renal disease 25%
Pregestational diabetes mellitus 20%
Class B/C diabetes 10-15%
Class F/R diabetes 35%
Thrombophilia 10-40%
Obesity/insulin resistance 10-15%
Age > 35 years 10-20%
Family history of preeclampsia 10-15%
Primiparity 6-7%
 PREVENTION IS THE BEST
PRACTICE
Pre-conception care
Investigations
• Blood pressure brp baseline tekanan darah, awal kehamilan tensi cenderung turun. makanya sekrg ada skriing layak hamil, calon
pengantin dll.
• Urinalysis
• Further specific investigations will be required if additional disorders
are suspected
Counselling
• Risks of preeclampsia and its effects
• Drugs, antihypertensive with fetotoxicity should be stopped before pregnancy
• Early referral for obstetric care
• Consider prophylaxis against preeclampsia
 Prevention is the best practice

PRE-CONCEPTION CARE
klo ngga di edukasi sblm hamil, maka akan menunda

Prophylaxis against preeclampsia

datang ke puskesmas. Harapannya saat ibu terdeteksi
hamil, bisa berkonsultasi dan diberi obat berikut

• Aspirin
• Calcium supplementation
• Antioxidants
• Fish oil Supplemantation
• Antihypertensives
 Management of preeclampsia complications

REMOTE PROGNOSIS
Patients with preeclampsia should be counseled
regarding risks for :

• Chronic hypertension
• Coronary artery disease
• Renal disease